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Reimbursement Advisor

Use of “complication” triggers Medicare denial

November 2006 · Vol. 18, No. 11

<huc>Q</huc> During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

<huc>A</huc> Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “When a complication described by codes defining complications arises during an operative session, a separate service for treating the complication is not to be reported.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.